Provider Demographics
NPI:1215570742
Name:MASON, LORETTA SUE (CDC I)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:SUE
Last Name:MASON
Suffix:
Gender:F
Credentials:CDC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 N RAINBOW PARK DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99623-9240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3001 C ST
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-3913
Practice Address - Country:US
Practice Address - Phone:907-273-4008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)